2. Prof. Ashraf Aminorroaya
Prolactinoma
Prof. Ashraf Aminorroaya
- Mar 2017

4. Hyperprolactinemia Pregnancy, postpartum, stress, nipple stimulation
Medications: Phenothiazines, methyldopa, cimetidine, metoclopramide, risperidone
Hypothyroidism
CRF (resistance of lactotrophs to dopamine, decreased clearance)
Chest wall lesions
Macroprolactin

6. Clinical Presentations
Premenopausal women:
-Hypogonadism (infertility, oligomenorrhea, or amenorrhea)
-Galactorrhea
Postmenopausal women:
Headaches, impair vision, rarely galactorrhea 
Men:
-Hypogonadism (decreased energy and libido, decreased muscle mass, body hair, impotence, infertility and osteoporosis)
- Galactorrhea, gynecomastia
-Headaches, impair vision
Pressure effect in both gender: loss of vision (superior temporal defects, bitemporal hemianopia, decreased visual acuity), headache (common), seizure (due to extension in temporal lobe) and hydrocephalus are rare, invasion to cavernous sinus and yet cranial nerve palsies are rare, pituitary apoplexy (cranial nerve palsies)

7. Diagnosis R/O secondary causes of hyperprolactinemia
PRL>250 ng/ml: Usually prolactinoma
PRL>200 ng/ml: Prolactinoma, some drugs
25 ng/ml <PRL<200 ng/ml & pituitary macroadenoma: R/O hook effect
(macroprolactinoma, non-prolactin secreting tumor)
Pituitary MRI

8. Prolactinoma
Microprolactinoma
Macroprolactinoma

9. Treatment Medical: Dopamine agonists
Bromocriptine: initial dose, 1.25 mg nightly, increased to 2.5 mg bid in 1-2 weeks, Doses larger than 7.5 mg/d are seldom needed but in macroprolactinoma
Microprolactinoma: 85%-90%: Nl. PRL in within days to a few weeks, Regular menses: a few months
Macroprolactinoma: visual field improvement within1-3 days and reduction in tumor size as soon as 2 weeks
Cabergolin: more effective than bromocriptine
Surgical: trans-sphenoidal

11. Monitoring of microadenoma treatment
Measure PRL & evaluate the side effects
after one month
Improve gonadal function: Within a few months
Decrease the dose after one year
Discontinue medication: Normal PRL> 2 years and Normal MRI

12. Postmenopause Discountine medication and measure PRL for follow up
PRL>200 ng/ml: Do MRI
Clinically important size: resume drug therapy

13. Macroadenoma management
Medical therapy regardless of size
Reassess vision within one month if initially abnormal (improvement may be observed within a few days)
Adenoma size decrease within weeks or months and can continue for years

14. Monitoring of macroadenoma therapy
Normal PRL > 1 years and markedly decreased size: decrease the dose gradually to keep PRL normal
Discontinue if initial size was cm and PRL normal >2 yrs and no mass lesion by MRI
Monitor PRL and Size indefinitely
Macroadenoma not met above criteria should be treated even after menopause

15. Surgical therapy Unsuccessful or untolerable medical therapy
Adenoma (>3cm) in women wish to become pregnant even if the respond to therapy
Giant adenoma (>4cm and PRL>1000ng/ml) may need surgery
Aggressive (invasive) PRL- secreting tumors

18. Dopamine agonist-resistant prolactinomas (DARPs)
Definition: failure to achieve normal PRL on maximally tolerated doses of dopamine agonist along with a failure to achieve a 50% reduction in tumor size
Treatment: Surgical debulking (± radiotherapy) and temozolomide, a chemotherapeutic alkylating agent

19. Radiation Not indicated in microadenoma
Not indicated as primary treatment of macroadenoma
Adjuvant therapy for surgically debulking macroadenomas (rapid tumor regrowth)
PRL normalize: 25%
Complications: hypopituitarism (12%-80%), optic nerve damage, neurologic dysfunction

20. Steroid replacement
Hypogonadism in premenopausal women with microprolactinoma who can not tolerate or do not respond to dopamine agonists
Hypogonadism in hyperprolacinemia due to antipsychotic agents:

23. Prolactinoma during pregnancy
Microadenoma
5.5% develop neurologic symptoms
Macroadenoma
36% develop neurologic symptoms

24. Prolactinoma and pregnancy
Microadenoma
Visit q3 mo, ask about headaches and changes in vision, if no symptom, measure PRL 2 mo after delivery or cessation of nursing

25. Prolactinoma and pregnancy
Macroadenoma
If adenoma is very large or elevates the optic chiasm: transsphenoidal surgery and perhaps postoperatively by radiation, with dopamine agonist and then pregnancy with normal PRL level
Macroadenoma not respond to medical therapy: pregnancy is discourage
If adenoma not elevate optic chiasma and respond well to medication do the same as microadenoma

26. Prolactinoma during pregnancy
Resume dopamin agonist if increased adenoma size impairs vision
Cabergolin is safe in pregnancy, data is limited

28. Breast feeding
Do if micro (macro)adenomas remained stable in size during pregnancy
Dopamine agonists should not be taken during breast feeding as because they impair lactation
Contraindicated in women who have neurologic symptoms, for example, visual field impairment, at the time of delivery, because they should be treated with dopamin agonists

29. Prolactin